INFORMATION SECURITY AGREEMENT

As an employee of the Veterans Health Administration (VHA) and as an authorized user of the computer systems of the
Department of Veterans Affairs (VA), I will be given access privileges to Federal data and computer systems, especially
computer systems within or accessible by VHA Staff, to perform the duties of my job. I understand the following policies apply
to these data and computer systems.

1. I will safeguard all security code(s) (I.e., VistA access, PC Network Access, electronic signature code) given to me. I
understand that I am not to use my access authority to a VA or other federal computer system, for any purpose other than
performance of my official duties. Specifically, I may not exceed the access authority provided by my security codes. I
acknowledge that I am strictly prohibited from disclosing my security code(s) to anyone for any reason except to the facility
Information Security Officer (ISO), VHA ISO, or Regional ISO. This includes my family, friends, co-workers, supervisors, and
subordinates.

2. I acknowledge that I am not to use anyone else's security code(s) to obtain access to VA or other Federal computer
systems. I understand that I will be held accountable for all work performed or changes made to the system and/or databases
under my security code(s) that I am not to allow to allow anyone to access a computer system using my security code(s).

3. I understand that all data to which I may obtain access is and will remain the property of VA. I understand that, as an
employee, I have an obligation to protect data and information which the loss, misuse, or unauthorized modifications of or
unauthorized access to could adversely affect the conduct of VA or other Federal programs. Further, I am aware that
information about individuals is confidential and must be protected by law and regulations from unauthorized disclosure.

4. I understand that improper access to, or unauthorized modification or disclosure of data (obtained through the computer or
otherwise) may subject me to the imposition of criminal penalties and/or disciplinary or adverse action, as appropriate, under
the VA employee conduct regulations. Similarly, if I exceed my computer system access authority or use that authority to
engage in conduct outside the scope of my official duties, I may also be subject to disciplinary or adverse action, and criminal
prosecution. I also understand that I am not to access my own records (I.e., lab results, etc).

5. I understand that VA electronic mail (e.g., VistA, Microsoft Exchange) is to be used for official government business only. I
am not authorized to use electronic mail either for personal messages not related to the performance of my official duties or in
lieu of personal telephone calls. I understand that the ISO and computer staff have the authority to monitor the amount,
types, and contents of messages sent by individuals on electronic mail. I understand that electronic mail may not contain
confidential information.

6. I understand the United States copyright law which states that it is a federal offense to copy any application software
protected under this law. "You must treat the software like any other copyrighted material (e.g., a book or musical recording)
except that you may either (a) make one copy of the software solely for backup or archival purposes, or (b) transfer the
software to a single hard disk provided you keep the original solely for backup or archival purpose." I understand that I may
use a copy of the software registered to a personal computer, but I cannot copy it.

7. I understand that I many not install, including but not limited to downloading via the Internet, any program or software on
any government computer without prior written approval of the Information Management computer staff. I also understand
that I may not modify any system settings on a personal computer that will impact others' ability to accomplish their work.
User settings such as color and mouse click rate may be modified.

8. I understand that I have been given conditional privileges necessary to access Internet resources. I understand
access to these systems are intended for official VA business only. Internet access is achieved with federally owned
communication paths, hardware and software and should never be considered available for personal use. Internet
utilization is thoroughly monitored and audit trails are maintained to identify and resolve instances of non-
compliance. I understand that violation of this policy constitutes a disregard of local and national VA policies and
will result in appropriate. Disciplinary action as well as suspension or termination of privileges.

9. I understand than any unauthorized use of any government resource, including but not limited to, computers, e-mail,
Internet, or any other government system or property, is strictly prohibited and may subject me to disciplinary action, including
removal from Federal employment. I understand official use of government resources, as described herein, apply to me even
when I am in an off-duty status.

10. I affirm that I have read and understand the provisions of this Information Security Agreement. Furthermore, I
acknowledge my obligation to with this agreement; to maintain computer access security at all times; to conserve government
resources and to use government computers, e-mail, Internet or any other government item or property for official government
purposes only.
I have read and understand all of the above sections of this agreement and will abide by these rules as a computer user.

Employee Name (Please print) DOB Social Security Number

Employee Signature Date

NOTICE: Signature MUST be original. Incomplete forms will be returned without action.
 COMPUTER ACCESS CODE/MENU REQUEST
Service Line/Mail Code Room Number Phone Type of Request
_X_ New User ___ Name Change
___ Reactivate User ___ Other
___ Menu Add/Change
Employee Name Change Name To/Change Title To (For Name/Title Change)

«Name»
Last, First, Middle Initial Last, First, Middle Initial Title

Title Medical Student Social Security Number

Primary Menu Options (Use the Option Names) Fileman Access Code
Person Class (If applicable)
AGD PROVIDER MENU
User Class (If applicable) Medical Student
Secondary Menu Options (Use the Option Names) Security Keys
_____________________ _____________________ _____________________ _____________________
_____________________ _____________________ _____________________ _____________________
_____________________ _____________________ _____________________ _____________________
_____________________ _____________________ _____________________ _____________________
_____________________ _____________________ _____________________ _____________________

PN Document List (If Applicable) Consult Titles (if applicable)

Miscellaneous Information (Mail Groups, etc.)

Justification for Request

(Please type or print)

Note: If you are requesting menus outside of your service line, you must also obtain that package's ADP Coordinator's concurrence
Application Coordinator or Service Line Director Signature Concurrence(s) (if necessary) Date

(No Stamps or Photocopying of Signatures Permitted)

PLEASE DO NOT WRITE BELOW THIS LINE
User Number: Access Code:

Processed by: Date

Director, Information Management Date Status

___ Approved

___ Disapproved

NOTICE: Signatures MUST be original. Incomplete forms will be returned without action. Revised: 10/99